Ulcerative colitis

Question 1

What is the definition of UC?

Answer 1

The chronic relapsing and remitting inflammatory disease affecting the large colon.

It starts at the rectum and spreads proximally. Always continuous.

Question 2

What are the risk factors?

Answer 2

unknown

genetic component - Ch 12 and 16

Other factors involved - immune response to bacterial or self-antigens, environmental

immune cells such as Il-13 (Th2 mediated)

15% have family history

Associations:
Elevated serum pANCA
Primary sclerosing cholangitis (70% of patients with PSC have UC)

Question 3

What is the epidemiology?

Answer 3

Higher in:

• Ashkenazi jews
• Caucasians

uncommon before the age of ten

peaks at 20-40.

Equal in genders until 40 where there is a larger number of males

Question 4

What are the symptoms of UC?

Answer 4

Bloody or mucous diarrhoea

Weight loss

Tenesmus or urgency

fever

Extraintetstinal - uveitis, erythema nodosum, pyoderma gangrenosum, sclertitis)

Crampy pain before passing stool

Question 5

what are the signs of UC?

Answer 5

unexplained iron deficiency anaemia

weight loss

Conjunctiva pallor

clubbing

extraintesinal - uveitis, erythema nodosum, pyoderma gangrenosum, sclertitis)

abdominal tenderness

Blood, mucous and tenderness on the PR exam

dehydration

tachycardia

Question 6

what are the investigations?

Answer 6

FBC - WBCC up, Hb down and platelets up

LFT - albumin down

Us and Es

ESR and CRP (up)

AXR

Stool culture (to rule out infectious colitis)

Sigmoidoscopy or colonoscopy

Barium enema

Question 7

What is the management for UC?

Answer 7

Acute Exacerbation
IV rehydration 
IV corticosteroids 
Antibiotics 
Bowel rest 
Parenteral feeding may be necessary 
DVT prophylaxis 
If toxic megacolon - the patient is likely to need a proctocolectomy because toxic megacolon has a high mortality 

Mild Disease
Oral or rectal 5-ASA derivatives (e.g. mesalazine, olsalazine, sulphasalazine) and/or rectal steroids

Moderate to Severe Disease
Oral steroids
Oral 5-ASA
Immunosuppression (with azathioprine, cyclosporine, 6-mercaptopurine or infliximab (anti-TNF monoclonal antibody))

Surgery:
Will be more curative than crohn’s and will form an ileo-anal pouch.

Question 8

what are possible complications of UC?

Answer 8

Gastrointestinal Complications
Haemorrhage 
Toxic megacolon – this refers to acute toxic colitis with dilatation of the colon (colon diameter > 6cm). This is a medical emergency as there is a big risk of perforation.
Perforation
Colonic carcinoma 
Gallstones 
Primary sclerosing cholangitis 

Extra-gastrointestinal Manifestations
Uveitis 
Renal calculi
Arthropathy
Sacroiliitis 
Ankylosing spondylitis 
Erythema nodosum
Pyoderma gangrenosum 
Osteoporosis (from chronic steroid use) 
Amyloidosis

Question 9

what is the prognosis for UC?

Answer 9

good prognosis.

This is decreased by:
Low albumin (< 30 g/L)
PR blood 
Raised CRP
Dilated loops of bowel 
8+ bowel movements per day 
Fever